Error, stress, and teamwork in medicine and aviation: cross sectional surveys
Sexton, Thomas and Helmreich compared perceptions of error, stress and teamwork in medicine and aviation, which they note no formal study had done, with an instrument aviation already had: a core set of 23 items from the cockpit management attitudes questionnaire, lightly reworded for operating theatres and intensive care. Theatre staff at 12 hospitals in five countries returned 851 questionnaires and intensive care staff at one large US teaching hospital returned 182. Over 30,000 pilots returned the aviation questionnaires over 15 years, with Latin America and Asia, unsampled in medicine, left out, though the pilot column of the paper's table, the base of its pilot percentages, numbers 7,558, a difference the paper does not explain.
Asked whether they perform effectively during critical times even when fatigued, 26% of pilots agreed, against 70% of consultant surgeons and 47% of consultant anaesthetists. Asked whether junior team members should not question the decisions of senior ones, 97% of pilots and 94% of intensive care staff rejected such steep hierarchies, against 55% of consultant surgeons. High teamwork with consultant surgeons was reported by 73% of surgical residents and 64% of consultant surgeons but by 10% of anaesthetic residents, and in intensive care by 77% of doctors about nurses but 40% of nurses about doctors. The paper reads a relationship between status and perceived teamwork: surgeons, most supportive of steep hierarchies, also rated teamwork higher than the rest of the team. Only a third of staff said errors are handled appropriately in their hospital. In intensive care a third did not acknowledge that they make errors, over half found mistakes difficult to discuss, and the reasons given for many errors being neither acknowledged nor discussed led with personal reputation (76%) and the threat of malpractice suits (71%).
In their aviation experience poor communication equates not to an obstinate captain but to poor threat and error management at the team level, so future research should not focus exclusively on consultants. Many aviation approaches to team training are likely to be useful in medicine, they add, but their design and effect need full validation. The bridge to psychological safety is ours, since the paper never uses the term: we read the item on questioning seniors as an attitudinal measure of whether voice across a hierarchy is legitimate, and the status gap in teamwork ratings as a caution that the view from the top of a team is not the team's view.
Sexton, Thomas and Helmreich call the small sample of hospitals the most important limitation and the data preliminary. The analysis is descriptive, the sample not large enough for multilevel modelling; two hospitals were excluded because their samples were not representative; and survey data rely on self-report and may be biased by non-response. Preliminary observations of theatre teams are said to suggest the attitudes are representative of behaviour, and the relationship of teamwork to error rates is left to future research.
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